From the Guidelines
For sinusitis with a penicillin allergy, I strongly recommend starting with a non-penicillin antibiotic such as trimethoprim-sulfamethoxazole or a macrolide, as these are cost-effective alternatives to amoxicillin, according to the clinical practice guideline on adult sinusitis 1. When managing sinusitis in patients with penicillin allergies, it's crucial to consider the severity of symptoms and the potential for spontaneous improvement.
- For patients with non-severe illness, observation for up to 7 days with symptomatic relief may be an option, as the guideline suggests that a high percentage of patients experience spontaneous improvement 1.
- For those with severe symptoms or who do not improve with observation, antibiotics such as trimethoprim-sulfamethoxazole or macrolides can be considered, given their efficacy and safety profile in penicillin-allergic patients 1.
- Symptom relief measures such as hydration, analgesics, and supportive therapies should also be emphasized to aid in patient recovery and comfort.
- It's also important to counsel patients on the natural history of acute bacterial rhinosinusitis (ABRS), the importance of adherence to antibiotic therapy if prescribed, and the potential for adverse effects, as outlined in the guideline 1.
- Given the penicillin allergy, it's essential to avoid amoxicillin and instead opt for alternative antibiotics that are effective against the common pathogens responsible for ABRS, as recommended by the guideline 1.
From the FDA Drug Label
For the treatment of acute bacterial sinusitis (ABS) using either 750 mg by mouth x 5 days or 500 mg by mouth once daily x 10 to 14 days Clinical success rates (defined as complete or partial resolution of the pre-treatment signs and symptoms of ABS to such an extent that no further antibiotic treatment was deemed necessary) in the microbiologically evaluable population were 91.4% (139/152) in the levofloxacin 750 mg group and 88.6% (132/149) in the levofloxacin 500 mg group at the test-of-cure (TOC) visit
Treatment of Sinusitis with Allergies to Penicillin:
- Levofloxacin can be used to treat acute bacterial sinusitis in patients with allergies to penicillin.
- The recommended dosage is either 750 mg by mouth x 5 days or 500 mg by mouth once daily x 10 to 14 days.
- Clinical success rates are 91.4% and 88.6% for the 5-day and 10-14 day regimens, respectively 2.
From the Research
Sinusitis Treatment Options
- For patients with sinusitis and allergies to penicillin, alternative antibiotics can be prescribed 3, 4.
- Amoxicillin-clavulanate is a suitable option for penicillin-allergic patients or those unresponsive to amoxicillin 3.
- Other alternatives include cefuroxime, cefpodoxime, or cefdinir 3.
- In cases of serious drug allergy, clarithromycin or azithromycin may be prescribed 3, 5.
Antibiotic Treatment Duration
- The optimal duration of therapy is unknown, but some recommend treatment until the patient becomes free of symptoms and then for an additional 7 days 3.
Diagnosis and Treatment
- Acute rhinosinusitis is a clinical diagnosis, and distinguishing between bacterial and viral sinusitis can be challenging 6.
- Cardinal features of acute bacterial rhinosinusitis include unilateral facial pain or pressure, fever greater than 102°F (39°C), and purulent nasal discharge with obstruction of the nasal passages 6.
- Antibiotics should be considered for patients with 3 or more days of severe symptoms, significant worsening after 3 to 5 days of symptoms, or 7 or more days of symptoms 6.